Provider Demographics
NPI:1013394261
Name:MADURAM, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MADURAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2509
Mailing Address - Fax:
Practice Address - Street 1:250 E SUPERIOR ST STE 4-2304
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2914
Practice Address - Country:US
Practice Address - Phone:312-926-5522
Practice Address - Fax:312-695-5645
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361631922085R0202X
OH35.1417262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology